Relationship between appearance and psychological distress in rheumatic diseases

Patients with rheumatic disease can experience physical deformities, especially of the hands and feet in the case of rheumatoid arthritis (RA), or skin rashes and lesions and hand deformity in the case of systemic lupus erthyematosus.

Few studies on body image concerns have been conducted, but research shows that women with lupus and RA have poorer body image than healthy women. A new study published in the March 2007 issue of Arthritis Care & Research examined the relationship between physical appearance concerns and psychological distress (depression and anxiety) in patients with RA and lupus.

Led by Louise Sharpe, Ph.D., of the University of Sydney in New South Wales, Australia, the study included 157 patients with lupus, newly diagnosed RA, or chronic RA. Patients completed a different set of questionnaires regarding their health because many RA measures are irrelevant to lupus. The survey evaluated disability, health related quality of life (HRQOL), psychological distress (including perceived appearance), and coping strategies. In addition, the RA patients underwent joint assessments by a rheumatology nurse; similar measures are not available for lupus patients.

The results showed that all groups showed increased psychological distress and the lupus patients' HRQOL was negatively affected. Also, 53 percent of the lupus patients reported that they felt unattractive because of the disease, compared with only 30 percent of those with chronic RA and 34 percent of those with newly diagnosed RA.

The study found that both appearance and physical disability are predictive of depression, but not anxiety, in patients with RA, suggesting that appearance concerns are important and are related to depression independently of disability. In lupus patients, the study found that appearance concerns mediated the relationship between physical HRQOL and depression; when appearance was taken out of the equation, physical HRQOL did not affect depression. The results also confirmed that appearance concerns are frequently associated with rheumatic diseases, with 30 to 53 percent of participants reporting that they felt unattractive due to changes in their appearance brought on by the disease.

Because previous research has shown high rates of depression in RA and lupus patients and elevated distress can affect function and quality of life, the researchers state, "By investigating which factors affect distress, psychological therapies can be improved to target specific areas and minimize the psychological impact of the disease." They note that although their results clearly establish that appearance concerns are associated with depression, this does not mean that depression is caused by concerns about appearance.

"Given that depression has been found to predict future disability, any measure that can be taken to lessen the distressing impact of the disease on mood should be implemented," the authors state, adding that "Because there is a relationship between appearance concerns and depression, it seems likely that targeting appearance concerns may improve mood." They also suggest that the assessment of concerns regarding appearance should be part of routine treatment for patients with rheumatic disease, even if they do not appear disfigured. When concerns exist, they should be targeted using psychological treatments that have been shown to be effective, such as cognitive behavioral therapy.